for Individuals and Families is a product of BC Life & Health Insurance Company, an independent licensee of the Blue Cross Association. and the Blue Cross name and symbol are registered service marks of the Blue Cross Association. 13798 2/07 It s all about what works for you.
gives you the power to choose Affordable PPO solutions to meet your dental needs -- all designed to give you the power to choose. An ounce of prevention A healthy mouth is more than a great smile. And regular dental visits play a more important role in your overall health than you may think. Dentists not only help your teeth look good, they may also detect early warning signs of more serious health problems, like heart disease and diabetes. So putting off going to the dentist just doesn t make sense. That s why BC Life & Health Insurance Company created, dental coverage designed to keep you happy and healthy. Give yourself something to really smile about choose gives you the power to choose from: two networks - 100 and 200 four plans several price points Whether you choose a 100 or 200 plan, you have the power to visit any dentist or specialist in either of the two networks (or even in our larger 300 network) and still be considered in-network. Get reimbursed if you go out of network too. You also have the freedom to visit a dentist outside of our network altogether if you want. Keep in mind, however, you will usually save the most money when you visit a dentist within the network YOU selected. It s easy to stay in-network, because has the largest PPO dental network in California. A network of specialists The time might come when you need or want a specialist -- like an oral surgeon, an endodontist or a periodontist. At times like this, it'll be good to know that all of the specialists participate in all of the networks. No referrals necessary! 2 3
Which plan is right for you? If you already have a dentist you like and don t want to switch: Check our Provider Finder at bluecrossca.com and see if your dentist is in one of our networks. If your dentist is in the 100 network, the best plan for you is either 100 Basic or 100 Plus (see pages 6 and 7). If your dentist is in the 200 or 300 network, the best plan for you is either 200 Plus or 200 Essential (see pages 6 and 7). If your dentist is not in any of the networks, review the out-of-network coverages shown on pages 6 and 7 to determine which plan is best for you. The Benefits of All networks offer: 18,000+ dental professionals to choose from No deductibles for cleanings, exams and X-rays No claim forms or paperwork to deal with Discounts on popular services like whitening, implants and braces Dental Specialists within both networks Continued savings even after you reach your annual maximum. You keep saving because you pay OUR negotiated (and less expensive) fee, not full price, for dental services. If you don t have a regular dentist or if you don t mind switching to save money: Check our online Provider Finder at bluecrossca.com to find a network dentist close to you. If you find a dentist in the 100 network, the best plan for you is either 100 Basic or Dental Blue 100 Plus (see pages 6 and 7). If you find a dentist in the Dental Blue 200 or 300 network, the best plan for you is either 200 Plus or 200 Essential (see pages 6 and 7). 4 5
Plans Plans You have choices 100 Basic provides 100% in-network coverage for cleanings and X-rays -- and with no waiting periods. Certain Basic Services are covered at 80%. While this is the lowest priced plan, there's no coverage for Major Services. 200 Essential also provides 100% in-network coverage for cleanings and X-rays. With this plan, all Basic and Major Services are included, although waiting periods apply. Also, coverage for Basic and Major Services is based on a fee schedule, so your out-of-pocket costs may be higher than with a co-insurance plan. Increase your benefits The 100 Plus and 200 Plus plans both offer 100% in-network coverage for cleanings and X-rays. For both plans, Basic Services are covered at 80% in-network and Major Services are covered at 50% in-network. 200 Plus has longer waiting periods, but the 200 provider network is larger. 100 Basic In/Out of Network In Out Annual Deductible $25 Waived for Preventive & Diagnostic Services Yes Annual Maximum $500 Preventive & Diagnostic Services (cleanings, exams, X-rays, sealants, space maintainers) Basic Services (fillings, stainless steel crowns for primary teeth, and pulpotomies only) Major Services (oral surgery, endodontics, periodontics, prosthodontics only) Orthodontics Services Out-of-Network Reimbursement Waiting Periods * For Fee Schedule, see certificate of coverage. No 100% Fee schedule* 80% - Fillings 50% - Stainless steel crowns, pulpotomies Not covered Not covered Fee schedule* No waiting periods Fee schedule* 200 Essential In/Out of Network In Out Annual Deductible (single/family) $50/$150 Waived for Preventive & Diagnostic Services 6 7 Yes Annual Maximum $1,000 Preventive & Diagnostic Services (cleanings, exams, X-rays, sealants, space maintainers) Basic Services (fillings, oral surgery) Major Services (endodontics, periodontics, prosthodontics) Orthodontics Services Out-of-Network Reimbursement Waiting Periods * For Fee Schedule, see certificate of coverage. No 100% Fee schedule* Fee schedule* Fee schedule* Not covered Fee schedule* 3 months for Basic Services, 12 months for Major Services 100 Plus 200 Plus In/Out of Network In Out In Out Annual Deductible (single/family) $50/$150 $50/$150 Waived for Preventive & Diagnostic Services Yes No Yes No Annual Maximum $1,000 $1,000 Preventive & Diagnostic Services (cleanings, exams, X-rays, sealants) Basic Services (fillings, space maintainers) Major Services (oral surgery, endodontics, periodontics, prosthodontics) 100% 80% 100% 80% 80% 60% 80% 60% 50% 50% Orthodontics Services Not covered Not covered 100 100 Out-of-Network Reimbursement Network Level Network Level 3 months for 6 months for Basic Services, Waiting Periods Major Services 12 months for Major Services
How does it work? Who pays for what We pay the dentist or specialist a set amount for particular services. What you pay out of your pocket depends on what network and plan you choose, if you stay within that network for services or if you go out of that network. Here s an example: Joann buys the 100 Plus plan, which covers her X-ray at 100% and a filling at 80% if she visits a dentist. With this plan, Joann pays a $50 annual deductible. Looking for a dentist? It is easy to find a dentist or specialist in your area. Go to the member site at bluecrossca.com and click on the Find a Doctor link. Simply search for local dentists who are within the networks. If you do not have access to the Internet, you may call (888) 315-2049 and a Customer Service Representative will be happy to help. The way we see it If Joann sees a dentist in this network: Dentist s Fee Negotiated Fee Pays Joann Pays 100 $395 $253 $179 $74 200 $395 $315 $179 $136 300 $395 $357 $179 $178 Jeff buys the 200 Plus plan, which also covers his X-ray at 100% and a filling at 80% if he visits a dentist. This plan also has a $50 deductible. It s all about you Our mission is to improve the lives of the people we serve. We understand the importance of good dental health and know that regular preventive care is the best way to promote good health. That s why we encourage healthy habits and regular dental visits. With access to a network that includes many quality providers in your area, you can feel confident that you ll have the power to choose the care that best suits your needs. If Jeff sees a dentist in this network: Dentist s Fee Negotiated Fee Pays Jeff Pays 100 $395 $315 $230 $85 200 $395 $315 $230 $85 300 $395 $357 $230 $127 Joann s monthly premiums will be lower than Jeff s, but Jeff will save more money on Basic and Major services if he chooses dentists in the 200 or 300 networks. Joann and Jeff also have the option of visiting non- dentists, but their out-of-pocket costs will likely be higher. Keep on saving! After you reach your annual maximum you keep saving, because you continue to pay our lower negotiated fees when you visit dentists. 8 9
Rating Areas Availability Availability may be limited in some counties. If you live in any of these areas, please review the Statement of Understanding on the application before choosing this plan. 10 Counties with Limited Availability Area 1: Lassen, Modoc, Plumas, Sierra, Trinity Area 2: Alpine, Amador, Calaveras, El Dorado, Inyo, Mariposa, Mono, Tuolumne Area 3: Colusa, Glenn, Humboldt, Lake, Yolo The rates listed on pages 12 and 13 are monthly rates. Please note that the monthly payment option is available only if you pay by a monthly checking account automatic premium payment or credit card. If you choose to pay bimonthly, simply multiply the by rate two. If you prefer to pay quarterly, multiply the rate by three. Rating Areas Area 1: Del Norte, Lassen, Modoc, Monterey (except 93451, 95076), Plumas (except 95981), San Benito (93930, 95004 only), San Luis Obispo (93426 only), Shasta, Sierra (except 95922, 95960), Siskiyou, Tehama (except 95963, 95973), Trinity (except 95526) Area 2: Alameda (95304, 95377, 95391 only), Alpine, Amador, Calaveras, El Dorado, Fresno (except 93245, 93313, 93618), Inyo (except 93527), Kings (93242, 93631, 93656 only), Madera, Marin, Mariposa, Merced, Mono, Nevada (except 95977), Placer (except 95668, 95692), Sacramento (except 94571), San Benito (except 93930, 95004), San Joaquin (except 94514), San Mateo, Santa Clara (94303, 95023 only), Sierra (95960 only), Solano (95690 only), Stanislaus, Sutter (95626, 95648, 95837 only), Tulare (93631, 93641, 93646, 93654 only), Tuolumne, Yuba (95960 only) Area 3: Alameda (except 95304, 95377, 95391), Butte, Colusa, Contra Costa, Glenn, Humboldt, Lake, Mendocino, Monterey (95076 only), Napa, Nevada (95977 only), Placer (95668, 95692 only), Plumas (95981 only), Sacramento (94571 only), San Francisco, San Joaquin (94514 only), Santa Clara (except 94303, 95023), Santa Cruz, Sierra (95922 only), Solano (except 95690), Sonoma, Sutter (except 95626, 95648, 95837), Tehama (95963, 95973 only), Trinity (95526 only), Yolo, Yuba (except 95960) Area 4: Los Angeles (90623, 90630, 90631 only), Orange (except 90638), Riverside (92883 only) Area 5: Los Angeles (except 93243 and except ZIP codes beginning with 906-912, 915, 917, 918 & 935), Ventura (90265 and ZIP codes beginning with 913 only) Area 6: Imperial, Kern (93558 only), Los Angeles (91709 only), Riverside (except 92883), San Bernardino (except 91766, 91792, 93516, 93555), San Diego Area 7: Fresno (93245, 93313, 93618 only), Inyo (93527 only), Kern (except 93536, 93558), Kings (except 93242, 93631, 93656), Los Angeles (93243, 93560 only), San Bernardino (93516, 93555 only), San Luis Obispo (93252 only), Santa Barbara (93252 only), Tulare (except 93631, 93641, 93646, 93654), Ventura (93252 only) Area 8: Monterey (93451 only), San Luis Obispo (except 93252, 93426), Santa Barbara (except 93252), Ventura (except 90265, 93252 and ZIP codes beginning with 913) Area 9: Kern (93536 only), Los Angeles (ZIP codes beginning with 906-912, 915, 917, 918 & 935 except 90623, 90630, 90631, 91709, 93560), Orange (90638 only), San Bernardino (91766, 91792 only) 11
Coverage Information Eligibility You and your enrolling dependents must be permanent, legal residents of the United States. You and your enrolling spouse must be age 64 3 4 or younger. Eligible dependents include: the subscriber s lawful spouse any unmarried child (of the subscriber or the enrolled spouse) under age 19 any unmarried child (of the subscriber or the enrolled spouse) ages 19 to 23, who qualifies as a dependent for federal income tax purposes the subscriber s or enrolled spouse s child, who Non-Duplication of Blue Cross Benefits If, while covered under this policy, the member is covered by another Blue Cross of California/ BC Life & Health Insurance Company Individual policy, he/she will be entitled only to the benefits of the policy with greater benefits. The Blue Cross Companies will refund any premium received under the policy with the lesser benefits, covering the time both policies were in effect. However, any claims payments made by the Blue Cross Companies under the policy with the lesser benefits will be deducted from any such refund of premium. Requirement for Binding Arbitration If you are applying for coverage, please note that continues to be both incapable of self-support due to continuing mental retardation or physical handicap, and who is at least one-half dependent BC Life & Health Insurance Company requires binding on the subscriber or enrolled spouse for support arbitration to settle any and all disputes against Blue Cross Date Coverage Begins of California/ BC Life & Health Insurance Company, The effective date of your plan is assigned by including claims of medical malpractice, and breach of BC Life & Health Insurance Company and can be contract and benefits. This means that you are waiving your any day of the month following approval. right to a jury or court trial for both medical malpractice claims, and any other disputes. California Health and Safety Code Section 1363.1 and Insurance Code Section Termination of Coverage 10123.19 require specified disclosures in this regard, Coverage ceases under the plan when: You do not including the following notice: It is understood that any pay the premium when due, subject to the grace dispute as to medical malpractice, that is as to whether period; the spouse is no longer married to the any medical services rendered under this contract were principal insured; a child fails to meet the previously unnecessary or unauthorized or were improperly, listed eligibility requirements; any member becomes negligently or incompetently rendered, will be determined enrolled in any other Blue Cross of California/ by submission to arbitration as provided by California law, BC Life & Health Insurance Company non-group and not by a lawsuit or resort to court process except as coverage; any covered member resides in a foreign California law provides for judicial review of arbitration country for more than six consecutive months or is proceedings. Both parties to this contract, by entering into absent from California for more than six consecutive it, are giving up their constitutional right to have any such months. You must notify BC Life & Health Insurance dispute decided in a court of law before a jury, and instead Company of all changes affecting any member s are accepting the use of arbitration. Both parties also eligibility. agree to give up any right to pursue on a class basis any claim or controversy against the other. 14 15
Exclusions and Limitations This is an overview only. A comprehensive description of Exclusions and Limitations is contained in the Combined Evidence of Coverage and Disclosure Form. EXCLUSIONS AND LIMITATIONS FOR DENTAL BLUE 200 ESSENTIAL, DENTAL BLUE 100 PLUS AND DENTAL BLUE 200 PLUS. EXCLUSIONS AND LIMITATIONS WITH AN ASTERISK (*) ALSO APPLY TO DENTAL BLUE 100 BASIC. Services not specifically listed in the Covered Services section of this Policy. Procedures not yet recognized by the American Dental Association as indicated with a specific procedure code designation, or procedures which are considered experimental or investigative in nature or which are not widely accepted as proven and effective procedures within the organized dental community. *Any condition for which benefits are recovered or can be recovered, either by any workers compensation law or similar law even if you do not claim those benefits. If there is a dispute or substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers compensation law or similar law, we will provide the benefits of this plan for such conditions, subject to the right to a lien or other recovery under section 4903 of the California Labor Code or other applicable law. *Any services you actually received that were provided by a local, state, county or federal government agency including any foreign government, except when payment under this Policy is expressly required by federal or state law. This Policy will not cover payment for these services if you are not required to pay for them or they are given to you for free. Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation. Any services for treatment of illness or injury that occurs as a result of any act of war, declared or undeclared. Any services for treatment of injuries sustained or illnesses resulting from participation in a riot or civil disturbance, or while committing or attempting to commit an assault or felony (unless otherwise required by law). Services, treatments or other care required while incarcerated in a federal, state or local penal institution or required while in custody of federal, state or local law enforcement authorities, including work release programs. *Services For Which You Are Not Legally Obligated To Pay: Services for which no charge is made to you in the absence of insurance coverage. *Expenses Before Coverage Begins or After Coverage Ends: Services received before your Effective Date or services received after your coverage ends. *Professional services received from a person who lives in the Insured s home or who is related to the Insured by blood, marriage or adoption. *Cosmetic Dentistry: Any services performed for cosmetic purposes (including but not limited to external bleaching, bleaching of non-vital discolored teeth, composite restorations, veneers, crowns on teeth not exhibiting pathology and facings on crowns on posterior teeth). 1 *Excess Amounts: Any amounts in excess of the dental benefit maximums and yearly Maximum Benefit stated in this Policy. The Covered Expense for all Covered Services includes the administration of any local anesthesia and the provision of infection control procedures as required by state and federal mandates. If billed separately, such charges will be denied. 1 *Procedures requiring Appliances or restorations (other than those for replacement of structure loss from tooth decay) that are necessary to alter, restore or maintain occlusions. These include but are not limited to: Changing the vertical dimension. Replacing or stabilizing lost tooth structure by attrition, abrasion, abfraction, erosion or bruxism. Realignment of teeth. Gnathological recording. Occlusal equilibration. Periodontal splinting Harmful Habit Appliances: Fixed and removable Appliances to inhibit thumb sucking. Replacement of an existing fixed or removable prosthesis for which benefits were paid if replacement occurs within seven (7) years of the original placement, unless the prosthesis is being used during the healing period for recently extracted anterior teeth. Replacement of crowns, inlays, onlays and laboratory-fabricated restorations if replacement occurs within seven years of the original placement. Benefits will not be provided for a pontic or an abutment if a fixed or removable partial, crown, or onlay was placed on the affected tooth/teeth in the last seven (7) years. Lost or Stolen Dentures or Appliances. Replacement of existing full or partial dentures or Appliances which have been lost or stolen. Charges for any duplicate prosthetic device or Appliance, or for a spare set of dentures or any other duplicate Appliance. 16 17
Exclusions and Limitations (cont.) *Prescribed drugs, pre-medication or analgesia including charges for nitrous oxide or any similar local anesthetic when the charge is made separately from a Covered Service. *Replacement of existing fillings for any purpose other than restoring active decay. The extraction of immature erupting third molars and nonpathologic, asymptomatic third molars is excluded. Third molar extractions are not covered under age 16. Histopathological exams (examination of cells by microscope) and/or the removal of tumors, cysts, and foreign bodies. *Charges for tobacco counseling, oral hygiene instruction, dietary planning, or behavior management. *Diagnosis or Treatment of the Joint of the Jaw and/or Occlusion: Services, supplies or appliances provided in connection with any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means; or *Treatment of congenital or developmental malformations including but not limited to cleft palate, maxillary and mandibular malformations, enamel hypoplasia, fluorosis, and anodontia. Personalization or characterization of dentures or teeth. Precision attachments and the replacement of part of a precision attachment. Overdentures and related services, including root canal therapy on teeth supporting an overdenture. Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery, orthognathic surgery or any oral surgery requiring the setting of a fracture or dislocation. Prosthetics for Insureds under 16 years of age including but not limited to fixed bridges, dentures, removable partials, crowns, inlays and onlays. Denture adjustments, repairs, relines and rebase are not covered for a period of six (6) months from initial placement if the denture(s) were paid for under this Policy. Fixed Prosthodontics are not a Covered Service when all molars are missing on one or both sides of an arch. Benefits are provided for the replacement of an existing bridge if it is seven (7) years old or older and cannot be made serviceable. Temporary and interim prosthetics (temporary crowns, bridges, partials, dentures, etc.). Temporary services are considered an integral part of the final services rather than a separate service, and are therefore not eligible for benefits. *Implants: Materials implanted into or on bone or soft tissue and all adjunctive services (including but not limited to surgery, prosthetics placed on implants, cleanings, maintenance, etc.) performed in conjunction with the placement or removal of implants. 1 Occlusal guards, occlusal adjustments (complete or limited) and occlusal analysis. *All hospital costs and any additional fees charged by the Dentist for hospital treatment. Professional visits for house/extended care facility, office visits after regularly scheduled hours, and case presentations. Teeth lost prior to coverage under this Policy are not eligible for prosthetic replacement unless the prosthetic replacement replaces one or more eligible natural teeth lost during the term of this coverage. *Services or treatments that are not Medically Necessary. Medically necessary services or treatments are those which are ordered by the attending Dentist for the direct care and treatment of a covered condition. They must be standard dental practice where received for the condition being treated and must be legal in the United States. If more than one treatment plan would be considered Medically Necessary for a dental condition, any amount exceeding the cost of the least expensive professionally acceptable treatment plan is not covered. Charges for missed or cancelled appointments. *Orthodontic services, cephalometric film, braces, appliances and all related services including surgery necessary in conjunction with orthodontic treatment. *Transfer of care: If a Policyholder transfers from the care of one Dentist to that of another Dentist during the course of treatment, or if more than one Dentist renders services for one dental procedure, BC Life & Health shall be liable only for the amount it would have been liable for had one Dentist rendered the services. *Services for treatment of malignancies and neoplasms. Complications of Non-Covered Services: Complications arising from non-covered Services and supplies. Examples of Non-Covered Services include, but are not limited to: cosmetic surgery, or operations and procedures which are determined to be experimental or investigational. Claims received after 12 months from the date service was rendered. 18 19
Exclusions and Limitations (cont.) ADDITIONAL EXCLUSIONS AND LIMITATIONS FOR DENTAL BLUE 100 PLUS AND DENTAL BLUE 200 PLUS Osseous grafts if the following procedures have been performed on the affected tooth or site on the same date of service or within the previous 12 months: Apicoectomy Retrograde Filling Root canal therapy Fixed Bridges are covered only when: The bridge is replacing teeth that were extracted after the Insured s Effective Date; and The total units required to replace all missing teeth is six units or less in an arch (arch means maxilla or mandible); and The bridge or bridges consist of no more than six (6) units total in an arch. (Each abutment is a unit and each pontic is a unit in a bridge.) Coverage for fixed bridgework that includes more than a total of six (6) units is limited to the amount this Policy would pay for a removable partial denture. ADDITIONAL EXCLUSIONS AND LIMITATIONS FOR DENTAL BLUE 100 BASIC Services not specifically listed in the Benefit Schedule section of the Policy. 1 Charges for treatment by other than a licensed Dentist, except charges for dental prophylaxis performed by a licensed dental hygienist. Oral evaluations exceeding two visits per Year. Prophylaxis (teeth cleaning) exceeding two per Year. More than one set of full-mouth X-rays or its equivalent in a five (5) year period. Fluoride applications: if you are over eighteen (18) years of age exceeding two per Year Periapical and bitewing X-rays submitted singly will be combined and paid up to the amount of a full mouth series and are subject to the full-mouth X-ray limitation. No more than one (1) bitewing X-ray series in a Year will be covered. No more than eight (8) films for vertical bitewings in a 60 month period will be covered. Fillings exceeding one per Year per surface per tooth if you are under the age of 19 and one every three (3) years per surface per tooth if you are age 19 and older. If a tooth or teeth can be restored with amalgam (with the exception of composite resin on anterior teeth), any amount exceeding the cost of that material is not covered if another material is used. Anterior teeth exhibiting pathology eligible for composite restorations are central incisors, lateral incisors, cuspids and the facial surface of bicuspids. Services for oral surgery, for example, tooth extractions. Services for endodontics, for example, root canals. Endodontics means the branch of dentistry dealing with diseases of the tooth pulp. Services for periodontics, for example, scaling and root planning. Periodontics is the dental specialty of treating periodontal disease. Services for prosthodontics, for example, crowns. Prosthodontics is the branch of dentistry dealing with the construction of artificial appliances for the mouth, especially for the purpose of replacing missing teeth with bridges and dentures. 1 Even though these services are not covered as part of the dental plan, discounted fees for these services are available from in-network dentists. 20 21
How to enroll? For new members enrolling in dental coverage only: Determine your premium Choose your payment plan Complete and sign the attached application Write a check payable to BC Life & Health Insurance Company Send the application and payment to the address below, or to your agent For new members enrolling in Blue Cross of California/BC Life & Health Insurance Company medical and dental coverage: See instructions on the Individual Enrollment Application For Blue Cross of California/BC Life & Health Insurance Company medical members who want to add dental: Complete the attached application Determine your premium Choose your payment plan* Write a check payable to BC Life & Health Insurance Company. Send the application and payment** to the address below, or to your agent * You must select the same payment option for your dental plan that you have for your medical plan. **Even if you pay your medical premium by a monthly checking account automatic premium payment or credit card, you must send the first month s dental premium with the application. Receive discounts on teeth whitening, braces or implants from network dentists. To determine your initial premium:* If you want to pay your bill monthly, fill out the attached Checking Account Deduction Authorization and submit it, along with a check for one month s premium and a blank check marked VOID. If you want to pay your bill every other month (bimonthly), write a check for two months premium. If you want to pay your bill every three months: write a check for three months premium. *If you are a Blue Cross medical plan member, you must select the same payment option for your dental plan that you have for your medical plan. 22 Send your application and payment to: BC Life & Health Insurance Company P.O. Box 9051 Oxnard, CA 93031-9051 or to your: Authorized Independent Agent 23